Mental health services can be successfully integrated in primary care

CHICAGO – Mental health services can be successfully integrated into a primary care practice, potentially improving patient satisfaction, compliance with treatment, and follow-up compared with traditional external referrals. When done right, a pediatric practice also can make a profit.

“It’s convenient, it’s your office, and your patients know how to get there. It could increase compliance, and there is better follow-up for sure,” Jay Rabinowitz, MD, MPH, said. “It also reduces the stigma associated with mental health care.”

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“It’s easier, more efficient, and causes less stress from referrals,” he said at the annual meeting of the American Academy of Pediatrics. “You also gain knowledge and gain confidence from colleagues.”

The kinds of mental health disorders you want to manage in your practice, how you plan to schedule the longer appointments, and what kind of providers you foresee hiring are among the initial considerations. You also need to figure out how to pay a psychologist, social worker, or certified counselor.

Define the diagnoses you wish to see ahead of time, said Dr. Rabinowitz, who is in private practice at Parker Pediatrics near Denver and a clinical professor of pediatrics at the University of Colorado at Denver, Aurora. In his office, he and his colleagues typically refer internally for evaluation or management of ADHD, depression, anxiety, behavioral problems, adjustment disorders, drug counseling, and behavioral addictions. In contrast, they tend to refer out education testing because “it takes a lot of time, and you cannot bill insurance for it anyway”; patients with autism because there are specialty centers nearby; and difficult divorce cases because they consume a lot of time and resources. In general, any behavioral health issues that appear likely to require 20 or more visits to address also are referred to specialists outside the practice.

When first integrating behavioral health services, scheduling the typical 50-minute visits can be a challenge for staff accustomed to the 20-minute clinical time slots. Schedulers also need to confirm that all patients at the practice have a physical examination first and complete the different consent and privacy forms. In addition, mental health counseling sessions get canceled a lot, he said, so his practice maintains a “move up” list and a late cancellation/no-show policy. “These are expensive 50-minute visits.”

The practice has a dedicated waiting room for mental health appointments. Also, “initially we used exam rooms; that was fine for a while. But eventually we remodeled and have some nice consult rooms that are carpeted with comfortable chairs,” Dr. Rabinowitz said. “I like using the rooms sometimes when [patients] are not there for consults.”

Choosing and paying your colleagues

Decide what kind of work arrangement makes the most sense for your practice, Dr. Rabinowitz said. Options include hiring providers as employees of the practice, as independent contractors, or based on a space-sharing agreement where they rent space in the office.

Some primary care practices contract with psychiatrists, psychiatric nurse practitioners, social workers, and/or licensed counselors. Parker Pediatrics employs two PhD child psychologists. In response to an attendee question about how the practice pays the psychologists, Dr. Rabinowitz said, “Initially it was hourly. But we now have a formula that if you bill this amount, you make this, so it’s performance-based.” He added, “They do pretty well. I think we pay them better than they could make on their own.”

“Our [pediatricians] love this. It is so much easier than the old system where they had to refer out and try to follow up. There is better communication and, of course, better follow-up for the children, too.” Dr. Rabinowitz added, “You meet the needs of families and patients – that’s obviously very important. Plus it attracts new patients. There could be some income involved, too – that always is an advantage.”

In response to another attendee question about profitability, Dr. Rabinowitz said, “We make a decent profit on them, although the goal isn’t to make a gigantic profit.”

Better reimbursement needed

A concierge-type mental health service, where patients pay out of pocket, is not an economic option for Medicaid and many other patients, Dr. Rabinowitz said. In addition, “mental health networks are great, but there is poor reimbursement for those.” He recommended pediatricians search for grants – his practice initially had a grant to see Medicaid patients – and to check state and local regulations about reimbursement for mental health services. In most cases, a practice cannot bill on the same day for a medical and mental health visit, with the exception of a flu shot, he said.

“Then there is financial integration, which is what we do. We can bill incident to our psychologists as long as we’ve done an initial physical exam, which we do.” The pediatric practice does all the billing, collection, and other financial services for the psychologists they employ; this allows the psychologists to bill under the physician’s name and receive a higher rate of reimbursement.

Negotiate contracts with insurance companies to include integrated mental health services and remember to get malpractice insurance that includes the additional providers, he added.